ED Coding and Reimbursement Alert

On your laceration claims, be sure to prove that the ED physician provided care that qualifies for the laceration repair codes.

Medicare also has some different rules for certain repairs using Dermabond -- if you code these encounters as you would for a private payer, you-ll likely end up with a denial.

When the physician treats lacerations, you might be tempted to flip to the laceration repair section of CPT and choose a code. But before you do that, you-ll need to make sure that the service meets payer definition for a repair.

If the ED physician uses staples, stitches or sutures to close a wound, you can code laceration repair. But if the physician (or staff) uses only steri-strips, or some other kind of adhesive strip, to close the wound, you should consider the work an E/M service, says Kevin Solinsky, CPC, CPC-I, CPC-ED, president and CEO of Healthcare Coding Consultants LLC, Added Value Billing Inc.

Use an E/M code "when the adhesive strips are the sole repair material. If the adhesive is used in addition to sutures, staples, or tissue adhesives, then report the appropriate [laceration] repair code," says Kevin Arnold, CPC, business manager for the Emergency Medicine Department at Connecticut's Norwalk Hospital.

Next, you should check the body area of the treatment. CPT groups laceration repair by anatomical location -- with a twist.

The grouping of anatomical locations for repair codes "depends upon which type of laceration repair you are doing," says Holly Barrett, CPC, CPC-H, ED and outpatient surgery coder at Northeastern Vermont Regional Hospital in St. Johnsbury.

Check out these different anatomical breakdowns for laceration repair:

- Codes 12001-12007: Scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet)

- Codes 12011-12021: Face, ears, eyelids, nose, lips and/or mucous membranes.

- Codes 12031-12037: Scalp, axillae, trunk and/or extremities (excluding hands and feet)

- Codes 12041-12047: Neck, hands, feet and/or external genitalia

- Codes 12051-12057: Face, ears, eyelids, nose, lips and/or mucous membranes.

- Codes 13100-13102: Trunk

- Codes 13120-13122: Scalp, arms and/or legs

- Codes 13131-13133: Forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet

- Codes 13150-13153: Eyelids, nose, ears and/or lips.

Example: A patient with a simple 2.2-cm laceration on her nose presents to the ED physician. On the claim, you would report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less).

Medicare exception: When coding simple repairs for Medicare patients, be on the lookout for Dermabond. If the physician uses Dermabond as the only closure material for a simple repair, report G0168 (Wound closure utilizing tissue adhesive[s] only) for the service.

This is for simple repairs only. If the physician performs an intermediate or complex closure with only Dermabond for a Medicare patient, report a laceration repair code from CPT.

The rules regarding complexity of repair are pretty straightforward. A simple laceration repair involves a single-layer repair without any significant particulate debris or contamination.

For instance, if the ED physician uses surgical staples to close a single-layer 7.4-cm cut on a patient's left leg, you-d report 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm) for the repair.

For intermediate repairs, the physician must perform layered closure of one or more of the deeper layers of subcutaneous tissue and superficial non-muscle fascia in addition to the skin, Arnold says. You can also report an intermediate code if the physician performs a single-layer repair that is heavily contaminated and requires extensive cleaning or removal of particulate matter.

Warning: The simple laceration repair codes have some cleaning and particulate removal figured into their work units. Make sure your physician goes "above and beyond" this work before considering an intermediate code, Arnold says.

Example: A construction worker presents to the ED following a power saw mishap that caused a 3.2-cm forearm laceration into the subcutaneous tissue and superficial fascia. The emergency physician performs a level-three E/M, examines and cleans the wound and performs a layered closure repair.

On this claim, report the following:

- 12032 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 to 7.5 cm) for the repair

- 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem- focused history; an expanded problem-focused examination; medical decision-making of moderate complexity) for the E/M

- modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) linked to 99283 to show that the E/M and laceration care were separate services

- 959.3 (Injury, other and unspecified; elbow, forearm, and wrist) linked to 12032 and 99283 to represent the patient's injury

- E919.4 (Accidents caused by machinery; woodworking and forming machines) linked to 12032 and 99283 to represent the cause of the patient's injury.

Patients reporting to the ED for complex laceration repair are rare; these patients usually head to the OR. However, your ED physician may perform a rare complex repair, so check out this explanation on the elements of a complex repair:

If the wound requires more than a layered closure, or the service includes scar revision, debridement of traumatic lacerations, or extensive undermining, it might be a complex repair. When you use complex repair codes, be sure the physician includes documentation explaining why the repair was complex.

When the ED physician performs multiple laceration repairs to the same patient during the same encounter, coding will depend on the repairs- types and location, Solinsky says.

"You will total all repairs of the same anatomical area that are the same level of repair," he says. For example, the ED physician performs three separate, simple 2-cm repairs to a patient's arm.

Since the fixes are all simple and in the same anatomical location, you should add up the lengths of the repairs and choose one code. In this scenario, report 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm) to account for all three repairs.

But suppose the physician makes two simple, 2-cm repairs to the patient's arm, and then has to make an intermediate repair on another 2-cm arm injury. In this scenario, you-ll need two codes. On the claim, you would report the following:

- 12002 for the simple arm repairs

- 12031 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) for the intermediate repair.

You should also submit separate codes for repairs the physician makes in different anatomical locations, regardless of repair levels.

Example: The notes indicate that the ED physician made the following repairs:

- a 3.1-cm simple repair on the face

- a 2.2-cm intermediate repair on the neck

- a 7.2-cm intermediate repair on the right forearm.

On the claim, you would report the following:

- 12032 (- 2.6 cm to 7.5 cm) for the forearm repair

- 12041 (Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less) for the neck repair

- 12013 (- 2.6 cm to 5.0 cm) for the face repair.